Dementia Therapeutic Environments: Cultural, Social, and

Physical

Kathleen Garvey, OTRL, CAPSDementia Care Specialist, UMRC, Towsley Village

October 7, 2017Michigan Occupational Therapy Association

Fall Conference, Grand Hotel

Descriptors: Demented, Sufferers, Subjects, Victims, “ Not all there”Exclusion from discussion, planning and decisions about what is “dementia friendly”Exacerbation of social inequality, stigma, isolation, loss of identity and discriminationAuthenticity of voice versus tokenistic and patronizing inclusion for fundraising or media attentionDiagnosis= Prescribed Disengagement

Research Bias and Exclusion

(Swaffer, 2014)

Framework for analyzing long term services and supports (LTSS) programs.Adapted and expanded from Kane, Kane, and Ladd, 1998, p. 162, and Wilson, 2007, p.10.

1. Unobtrusively reduce risks.2. Provide a human scale.3. Allow people to see and be seen.4. Reduce unhelpful stimulation.5. Optimize helpful stimulation6. Support movement and engagement.7. Create a familiar space.8. Provide opportunity to be alone or with others.9. Provide links to the community.10. Respond to a vision for a way of life.

Dementia Friendly Designs

Affordances Barriers

Open plans, automatic doors and elevators, movement between floors and in communal areas, garden

Closed doors, heavy doors and thresholds hindered movement

Variation in rooms for different activities, rest, changes

Long corridors made self mobility more challenging

Smooth flooring and safety devices in apartments and dining room

No handrails in building

Garden between buildings created safe outdoor space

Steep slope and traffic noise hindered outside activity

Large windows, access to daylight and visibility of outside activity observations

Small private rooms limited mobility, activities and opportunities for social interaction

Residential area, smooth ground and walking loop

Large dining room =loud noises

Large private rooms, space for personal belongings, sense of home

Feature Advantage Examples

Flexible spaces Allow for free roaming lack of orientation or destination

Way finding, walking, therapy or individual activity

Multiple Cueing Systems Reaching a destination, enriched environment, encourage movement and reminders

Plan forms, landmarks,grouping of chairs or single, Signage: arrow/stop sign, familiar icons

Comprehensible plans and bedroom groups

Reduces confusion and institutional impact

Shapes which allow place to pause, landmarks to assist navigation (bays, mats, pictures), proximity to activity space.

Openness and privacy Doors to allow choice for level of engagement

Safe locking

Variety of spaces Matching mood and encompassing a wide range of differing realities

Size, view, atmospheres, textures, colors, sensory stimulating features, variety of experiences and recall to reassure and calm.

Feature Advantage Example

Provision for animals Source of comfort, increase socialization, reduce agitation, benefit care partners

Birds, cats, dog, donkeys, chickens, geese, etc.

Visuoperceptual safeguards and aids

Removal of hallucination triggers : heavy shadows, stains, patterns

Contrasts and visual clues: floor, position of door, bathroom, stair treads

Icons and Cues Use of non verbal visual aides to encourage new habits or ressurect old ones

Shapes, signs, colors, objects, bright color on bathroom door.

Strong visual relationship to the exterior

Take advantage of available space to encourage usage, conversational prompt

Awareness of nature, seasons, weather, venturing, and exercise.

Challenge and exercise Offer personal and shared experience, roles for resident, relatives, care partners

Memory trail, stairs

Quality of Life (QoL)Stewart-Archer, Afghani, Toye , Gomez, 2016, Canada

• Subjective definition:– Freedom: unrestricted ability to do what one wants– Basic needs met produces feelings of well being and caring.– Independence to choose type, quality and quantity of help.– Tranquility to meet need for safety, security and comfort.– Meaningfulness be yourself, by yourself to preserve

meaning and worth.– Good physical health

• Self determination reaffirmed with continuance of even small decisions

Caring Organization

Characteristics Type A Type B

Manager’s Role Authoritarian, remote

Exemplary, accessible

Staff status divisions Large, rigid Small, flexible

Status of residents Lowest of all Equal to staff

Communication One way, impersonal Two way, interpersonal

Feelings/vulnerabilities Concealed In the open

Power differential High Low

Dementia Reconsidered, p. 106

Progression of Change

• Dementia Awareness• Dementia

Knowledgeable• Dementia Skilled• Dementia Competent

“Until there is a cure, there is care”-Teepa Snow, OTRL, FAOTA

• Understanding changes in brain structure and chemistry and how that affects perceptions, reactions, and abilities.

• Changing the social and physical environment to be accepting, supportive, and positive.

• Empowering care partners with new habits and routines to respond effectively so as to reduce stress and improve daily life for all.

• Tradition: containing the misfits, low status of care workers

• Power and prestige of the medical profession: limitations of diagnoses for care improvement

• Commercial interest in the promise of cure• Cost of person centered care and public sector

reimbursement• Personal defenses: distancing and

depersonalization

Barriers to Change

Act No. 476, State of Michigan, 90th Legislature, Regular Session of 2000, House Bill 5761 and 5762.

Fleming, R. et al (2016) The relationship between quality of the built environment and the quality of life of people with dementia in residential care. Dementia, 15(4), 663-

680.

Habell, M. (2013) Specialised design for dementia. Perspectives in Public Health, 133(3), 151-157.

Kane, R. and Cutler, L. (2015) Re-Imaginging Long-Term Services and Supports: Towards Livable Environments, Service Capacity and Enhanced Community Integration, Choice and Quality of Life for Seniors. The Gerontologist, 55(2), 286-295.

Kitwood, T. (1997) Dementia Reconsidered. New York: Open University Press.

Lee, S., Chadbury, H. and Hung, L. (2016) Exploring staff perceptions on the role of physical environment in dementia care setting. Dementia, 15(4), 743-755.

Sources for Presentation

Nordin, S. et al (2016) The physical environment, activity and interaction in residential care facilities for older people: a comparitive case study. The Scandanavian Journal of Caring Sciences, 1-12.

Phinney, A., Caudhury, H., O’Conner, D. (2006)Doing as much as I can do” The meaning of activity for people with dementia. Aging and Mental Health , 11(4), 384-393.

Richards, K. et al (2015) Comparison of a traditional and non- traditional residential care facility for persons living with dementia and the impact of the environment

on occupational engagement. Australian Occupational Therapy Journal, 62, 438-448.

Stewart-Archer, L. Afghani, A. Toye, C., Gomez, F. (2016) Subjective quality of life of those 65 years and older experiencing dementia. Dementia, 15(6), 1716-1736.

Swaffer, K. (2014) Dementia: Stigma, Language, and Dementia friendly. Dementia 13(6), 709-716.

Ward, R. Clark,A. Campbell, S. et al. (2017)The lived neighborhood: understanding how people with dementia engage with their local environment. International Psychogeriatrics, 1-14.

Dementia Western Australia, 2015. Dementia Enabling Environment Project, http://enablingenvironments.com.au.

Building dementia friendly communities, September 3, 2013. [ Illustration of 10 principles of creating dementia friendly communities. Copied from http://dementiapartnerships.com/resource/building- dementia-friendly-communities/.

Lum, F. (2013) In Pictures: Montessori Method for Dementia. (January 24, 2013) The Globe and Mail. Retrieved from https://beta.theglobeandmail.com/life/parenting/in-pictures-montessori-method-for-dementia/ article7794176/?ref=http://www.theglobeandmail.com&from=7819360